Reduce preventable admissions with a community hotline

February 6, 2012

In July 2009, leaders at Midland Memorial Hospital, a 223-bed hospital in Midland, Texas, established a 24-hour hotline for community members to call when considering an ED visit. At least one dedicated triage nurse manages the hotline at all times, and two additional nurses provide coverage during the peak interval between 11 a.m. and 5 p.m.

After listening to a caller’s concerns, the nurse provides guidance on whether or not an ED visit is warranted. If an ED visit is necessary, the triage nurse can page the patient’s physician or call 911 to dispatch an ambulance.

If an ED visit is not necessary, the nurse can arrange an appointment at a nearby urgent care center, federally qualified health center, or physician’s office. A unit coordinator follows up with all patients within 24 hours to ensure they have attended or plan to attend their scheduled appointments.

Importantly, the hotline’s dedicated triage nurse does not use clinical judgment alone to make each assessment. An evidence-based algorithmic system prompts the nurse with questions specific to the caller’s symptoms and provides guidelines that help inform the nurse’s decision.

Widely advertise hotline to community membersTo ensure community members are aware of the hotline, leaders at Midland promote the resource through multiple channels, including newspaper articles, radio interviews and advertisements, television commercials, refrigerator magnets, and flyers.

For institutions interested in replicating Midland’s practice, the precise wording of the community hotline flyer is included below:

Inappropriate demand, bad debt declineSince implementing the triage hotline, Midland has observed not only an overall decline in ED demand but, more significantly, a reduction in inappropriate demand. Of the more than 50,000 hotline calls since 2009, nearly two-thirds were triaged to lower-level care settings.

Leaders at Midland credit the hotline with helping to achieve a $5.5 million reduction in bad debt from non-emergent ED patients. Routing patients to a lower level of care also reduced costs to patients by 40%, or about $122 per call.

Twelve nurses in total staff the hotline, but Midland reports that—as a result of reduced ED volumes—the hospital did not need to add any FTEs to support the telephone triage position.

Hospitals shoot to get ban on guns

January 18, 2012

Florida hospitals are urging lawmakers to consider hospitals and nursing homes as weapon-free safety zones, but gun advocates argue that the proposal would limit a person's right to defend themselves.

Under Florida law, concealed weapons already are prohibited in schools, government buildings, athletic events, and bars and other businesses that are licensed to sell alcohol. The South Florida Hospital and Healthcare Association (SFHHA) has tried since 2000 to get the state Legislature to also ban guns in hospitals, and the issue again appears on the group's agenda for the 2012 legislative session.

"We just think it's a no-brainer. It's an emotionally charged environment," says Linda Quick, president of SFHHA, noting that hospital EDs often can be places of conflict. According to Quick, simply posting signs that guns are not allowed is insufficient protection; an individual with a state-issued concealed weapons permit could enter with a gun and not be arrested.

Meanwhile, the National Rifle Association (NRA) says it will continue to oppose gun bans in hospitals. "Very simply, people should not be denied the right to defend themselves just based on their choice of profession," says NRA spokesperson Andrew Arulanandam. "Just because someone's a doctor or a nurse, that doesn't mean they're less immune to crime."

According to Quick, a bill on the subject has yet to be filed during this legislative session. In recent sessions, lawmakers have taken pro-gun stances on many issues, the Miami Herald reports. For example, the state legislature last year passed a bill that bars physicians from discussing gun ownership with patients. A federal judge has blocked the law's implementation until she can determine whether it violates physicians' free speech rights (Dorschner, Miami Herald, 1/16; Moisse, ABC News, 1/17).

What does it take to become a hospital CEO?

Four former CFOs explain how they transitioned to the top post

January 18, 2012

How do top hospital finance officers make the transition to CEO? hfm Magazine this month talked with four former CFOs about their preparation before taking the helm.

According to hfm, hospital boards increasingly are considering CFOs as candidates for CEO, as organizations aim to balance quality and cost goals.

"Given the financial challenges of the industry going forward, CFOs are in a unique position to use their skill sets and apply them to a new role, like that of a CEO, to better position their organizations and meet the needs of the communities they serve," says Froedtert Health President Catherine Jacobson.

Rising to the topMany CFOs can grow into the CEO role as they learn the skills and fulfill the responsibilities associated with a C-suite job. For example, Jacobson only began to consider executive leadership after she became CFO and then the senior vice president of strategic planning and finance at Rush University Medical Center in Chicago.

"I would imagine scenarios that were way beyond my scope of responsibility," she says, adding, "It would keep me up at night, sometimes, thinking about how I would want to approach things on my own." She became president of Froedtert Health in 2011 after serving as a senior vice president for the organization.

According to Craig Kinyon, president and CEO of Richmond, Ind.-based Reid Hospital & Health Care Services, the CFO role prepared him for executive decision-making. "I can make a mental map of certain decisions we've made and rule in or rule out various scenarios and strategies because of my background and training," he says.

However, Phyllis Cowling, president and CEO of Wichita Falls, Texas-based United Regional Heath Care System, warns that the transition from CFO to CEO is not for everyone. Those who do make the transition quickly discover the stress of final responsibility. "I have responsibility for 2,000 employees, 200 physicians, and countless numbers of patients who depend on the decisions I make," she says.

Despite the potential stress, Agnesian Healthcare CEO Steven Little says the "exciting thing about being a CEO is the challenge, mentally and emotionally, to be the primary decision maker in a health system." Noting that talented CFOs often have leadership opportunities at their fingertips, he says it is "important to be willing to take some risk and step out of your comfort zone."

How to prepare for a broader rolehfm outlines several tips for CFOs considering a transition to CEO:

Learn how to speak without using financial language;

Seek out broader, more strategic responsibilities in your current role;

Learn how to manage around a board;

Be active in initiatives designed to improve care quality;

Take on responsibility for clinical departments;

Establish strong ties with physicians on the clinical staff;

Establish relationships outside of the hospital; and

Express your passion for being a health care leader (Williams, hfm, January 2012).

NYT: Physicians are biggest sector of wealthiest 1%

One in five physicians belongs to top earners cohort

January 18, 2012

Physicians are more likely than any other profession to be in the United States' wealthiest 1%, the New York Times reports.

Altogether, members of the wealthiest 1% earn at least $380,000 per year and account for nearly 20% of pre-tax income in the United States. The so-called 1% pays over 25% of federal taxes and accounts for 30% of philanthropic giving.

According to the Times, one in five physicians is in the wealthiest 1%. Specifically:

27.2% of physicians working in physicians' offices and clinics are in the 1%;

20.7% of physicians working in "health services" are in the 1%;

19% of physicians working for colleges and universities are in the 1%; and

17.2% of physicians working in hospitals are in the 1%.

The Times also notes that 3,519 CEOs or administrators in the health industry belong to the 1%, which accounts for about 13.6% of health care chief executives (Dewan/Gebeloff, Times, 1/14).

CMS proposes new definition of 'uninsured'

Update would affect DSH payments

January 18, 2012

CMS last week issued a proposed rule that redefines the word "uninsured" for the purpose of calculating uncompensated care payments.

The current definition of uninsured allows patients with any active insurance coverage to be considered insured, even if their insurance plan did not include coverage for the specific services they received. When the current rules were finalized in 2008, hospitals and state officials criticized them as too strict, classifying much uncompensated care as ineligible for reimbursement, according to Modern Healthcare.

Under the proposed rule, the definition of uninsured for purposes of reimbursement—known as disproportionate share hospital (DSH) payments—would be based on whether patients had insurance coverage for the specific services they received at the hospital. In addition, any services provided that are not covered because they exceed a plan's annual or lifetime limits also would deemed eligible for the DSH payments.

CMS will accept public comment on the new proposal for 30 days (Daly/Zigmond, Modern Healthcare, 1/13 [subscription required]).

Health reform lawsuit gains two new plaintiffs

Supreme Court grants NFIB request

January 18, 2012

The Supreme Court on Tuesday approved the National Federation of Independent Business' (NFIB) request to add two more plaintiffs to the multistate lawsuit challenging the federal health reform law.

NFIB's request came after another individual plaintiff in the case—Mary Brown of Panama City, Fla.—closed her auto repair shop and filed for personal bankruptcy, putting her legal standing to sue in question.

NFIB received permission to add Dana Grimes of Greenwich, N.Y., and David Klemencic of West Virginia. Grimes owns a building and home contracting services business, and Klemencic owns a flooring business.

The suit now includes four individual plaintiffs, NFIB, and 26 states.

In the brief, the lawmakers portrayed the lawsuit as a partisan squabble, adding, "The challengers' disagreement with the manner Congress has chosen to regulate the health insurance market is an occasion for political debate, not a matter for judicial imposition."

The brief adds that it is an "astonishing proposition" to argue that Congress cannot regulate health care, and maintained that the law was written with "careful attention to Supreme Court precedents defining the proper bounds of Congress' constitutional authority."

Further, they wrote that the arguments being pursued by the plaintiffs would "seriously undermine Congress's constitutional authority and its practical ability to address pressing national problems" (Carlson, Modern Healthcare, 1/17 [subscription required]; Norman, CQ HealthBeat, 1/17 [subscription required]).

January 18, 2012

After waging a roughly 20-year legal battle with the Internal Revenue Service (IRS), hospitals and former medical residents nationwide may receive a tax refund by the end of 2012, the Cleveland Plain Dealer reports.

From the mid-1990s through March 2005 teaching hospitals and medical residents paid taxes under the Federal Insurance Contribution Act (FICA) because the IRS treated medical residents as employees. However, no specific regulation at the time defined the tax status of medical residents, who argued that they were students and should not be subject to taxation.

The issue gained momentum in 1998, when a federal appeals court ruled that University of Minnesota medical residents were considered students and did not have to pay the FICA tax. According to the Plain Dealer, many medical school and hospital websites say 7,000 institution and individual protective refund claims were filed for a total of more than $1 billion.

The IRS in 2005 then altered its definition of a student to an individual who works less than 40 hours per week—medical residents typically work 60 to 80 hours per week and earn $40,000 to $50,000 annually. However, the agency said teaching hospitals and residents could be eligible for a refund for the taxes that had been withheld from Jan. 1, 1997 to March 31, 2005.

Although hospital officials say it is too early to speculate on the amount of the refund or how long it will take, IRS spokesperson Jennifer Jenkins said the agency anticipates that most of the payments will be doled out by Sept. 30, 2012 (Townsend, Plain Dealer, 1/15).

CNN: Many docs admit to cheating on radiology boards

January 18, 2012

Many physicians nationwide have cheated on the radiology board certification exams by memorizing test questions and providing those questions to others taking the test, according to a CNN investigation.

To become board certified, residents must pass two written tests and one oral exam during their five years of residency training. According to CNN, half of the exam is the same every year, while the other half changes.

Although radiology residents are required to sign a document that prohibits them from sharing test materials, many contribute to "sophisticated banks" of recall questions that provide that year's test questions to future test takers.

The American Board of Radiology (ABR) considers contributing to and using the recall banks cheating. "Accumulating and studying from lists of questions on prior examinations constitutes unauthorized access, is inappropriate, unnecessary, intolerable, and illegal," says ABR Executive Director Gary Becker.

For its investigation, CNN interviewed dozens of radiology residents who had promised to memorize certain questions and record them after the exam. CNN obtained at least 15 years' worth of recall test questions and answers, which were available on a radiology residents' website and on a shared military computer server.

Some professors in the past have encouraged the use of recall questions to study for the test, CNN reports. After failing one of the written radiology exams, Army captain Matthew Webb's program director at the San Antonio Uniformed Service Health Education Consortium told him to use the recall questions to pass the test. Webb filed a complaint about the recalls, which launched an ABR investigation into the practice.

Although ABR considers the practice cheating, many radiologists consider the recall questions a "gray area." Radiologist John Yoo says the recall questions are used primarily as a study guide. Meanwhile, radiologist Joseph Dieber says the test itself makes the recalls necessary. "Part of the problem is the test and the questions that they ask," he says, noting that "some of the questions are so obscure, that unless you know that they like to ask questions about that topic, you're not going to study it."

ABR revises exam to reduce cheatingIn response to the widespread use of recall questions, ABR is adopting a new testing procedure that relies more on concrete skills testing and less on memorized facts. According to an ABR fact sheet, the new board exams will "assess the doctors' abilities to actually interpret imaging studies and perform image-guided procedures." The new questions will be drafted by radiology experts. The test will continue to include some of the older test questions.

In addition, the new procedure eliminates the oral component, which had been criticized for being too subjective (Zamost et al., CNN, 1/13; Walker, MedPage Today, 1/17).

January 18, 2012

Executives on the move

This week’s industry transitions

January 18, 2012

Each week, the Daily Briefing highlights executive transitions among the nation's hospitals and health systems. Are you moving to a new institution? Please e-mail transitions@advisory.com to let us know.

Daily roundup: Jan. 18, 2012

Bite-sized hospital and health industry news

January 18, 2012

Colorado: The rate of central line-associated bloodstream infections (CLABSIs) in Colorado's adult ICUs fell by 43% over three years, according to a report from the state's department of public health and environment. Specifically, the CLABSI rate in 2010 was 0.89 infections per 1,000 central line days, compared with 1.57 per 1,000 central line days in 2008 (McKinney, Modern Healthcare, 1/15 [subscription required]).

Florida: About one-third of Florida medical expenses may be attributed to unnecessary tests and treatments ordered to avoid malpractice suits, according to a survey conducted by Oppenheim Research on behalf of the not-for-profit group Patients for Fair Compensation. Overall, 88% of the 327 physicians surveyed admitted to practicing "defensive medicine" within the past 12 months. Based on the findings, Patients for Fair Compensation estimates that more than $40 billion is spent on defensive medicine in Florida each year (UPI, 1/14).

Minnesota: Hospitals in the state provided $2.28 billion in community benefits in 2010, up 8% from the year before, according to a Minnesota Hospital Association report. Hospitals spent $226 million in charity care and $498.5 million treating Medicaid patients. Altogether, community benefits accounted for 11.6% of hospitals' operating expenses in 2010, up from 11.4% the year prior (Crosby, Minneapolis Star Tribune, 1/16).

Wisconsin: Gov. Scott Walker (R) has halted implementation of a health insurance exchange until the Supreme Court rules on the constitutionality of the federal health reform law but has not returned a $37 million federal grant for developing the exchange. According to Politico, Walker is the only Republican governor who has kept the Early Innovator grant. CMS spokesperson Brian Chiglinsky said, "We continue to be in touch and monitor the grant. Wisconsin still has the potential to provide help to other states based on systems already in place and the work that has already been done" (Nocera/Millman, Politico, 1/16).

Millions of smokers hide habit from their physicians

About 13% of smokers in the U.S. attempt to conceal their tobacco use from their physicians, according to a recent survey by the American Legacy Foundation (ALF), an anti-tobacco group.

For the study, ALF researchers—in conjunction with Pfizer—conducted an online poll that included 3,146 smokers and former smokers in 2011.

The findings showed that most survey respondents conceal the habit to avoid feelings of shame or having to face a lecture from their health care provider.

"Many smokers know why they should quit, but often don't know how," the report said. "Healthcare providers have an important role to play in helping smokers take that first step and helping smokers get on the path to quitting successfully."

The report suggested that physicians ask every patient whether they smoke, have a positive attitude when advising patients to quit, and arranging necessary follow-up to prevent relapses, among other recommendations (Phend, MedPage Today, 1/11).